HEALTH INFORMATION MANAGEMENT JOURNAL Vol 36 No 2 2007 ISSN 1833-3583 (PRINT) ... treatment and service utilisation in Victorian public hospitals. ..... is needed in the field of hospital data collection, .... Software International.
Reviewed articles
Ischaemic heart disease and Australian immigrants: the influence of birthplace and language skills on treatment and use of health services1 André Renzaho
Abstract Admission rates for ischaemic heart disease (IHD), and the use of invasive cardiovascular procedures, separation mode and length of stay (LOS) were compared between Australians from non-English speaking background (NESB; n=8627) and English speaking background (ESB; n=13162) aged 20 years and over admitted to Victorian urban public hospitals. The study covered the period from 1993 to 1998. It was found that, compared with their ESB counterparts, the incidence of admission for acute myocardial infarction was significantly higher for NESB men and women before and after controlling for confounding factors. The age-adjusted ratios for NESB women compared with their ESB counterparts ranged from 1.23 to 1.89 for cardiac catheterisation, from 0.23 to 0.27 for percutaneous transluminal coronary angioplasty (PTCA), and from 1.04 to 1.80 for coronary artery bypass grafting (CABG). Procedure rates were comparable in men for cardiac catheterisation and CABG but higher for PTA rates in NESB men (OR: 1.29, 95%CI: 1.11-1.50) than their ESB counterparts. Both NESB men (β=0.04, 95%CI: 0.01-0.07) and women (β=0.03, 95%CI: 0.02-0.08) experienced significantly longer hospital stays than their ESB counterparts. These findings indicate there may be systematic differences in patients’ treatment and service utilisation in Victorian public hospitals. The extent to which physicians’ bias and patients’ choice could explain these differences requires further investigation. Key Words (MeSH): Ethnicity; Non-English Speaking Background, Language Barriers; Invasive Procedures, Ischaemic Heart Disease; Cross-Cultural Comparison; Length of Stay; Physician-Patient Relations
Introduction Cardiovascular diseases (CVDs) together with diseases of circulatory vessels remain the leading causes of death in Australia (Australian Bureau of Statistics 1999; Australian Institute of Health and Welfare 2000b; Taylor et al. 1999) and in other developed countries (Health Policy and Public Health Directorate, 1995). Overseas studies have shown that migrants are more affected by CVDs and their risk factors than the host population (Erens, Primatesta & Prior 2001; Fang et al. 1996; Wild & McKeigue 1997). For example, a cross sectional analysis of mortality by country of birth over a 22-year period in England and 1
The study was undertaken as part of the author’s thesis for the Master of Public Health at the University of Melbourne.
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Wales (Wild & McKeigue 1997) found that, in comparison with the general population, South Asian men and women had the highest standardised mortality ratios for IHD, while the lowest ratios were observed among Caribbean and West African migrants. The same study found that mortality ratios for cerebrovascular diseases among migrants were higher than national averages and the highest ratios were observed among West African migrants. In the United States, black Americans have been reported to have threefold greater prevalence of CVD risk factors, namely hypertension, left ventricular hypertrophy and smoking, than their white counterparts (Lee et al. 2003). In Australia, epidemiological studies of the health of migrants have concluded that migrants
HEALTH INFORMATION MANAGEMENT JOURNAL Vol 36 No 2 2007 ISSN 1833-3583 (PRINT) ISSN 1833-3575 (ONLINE) 1
Reviewed articles generally have lower rates than the general population for a number of causes of death including CVDs (Young 1986) (see Table 1). One of the rare studies examining inequalities in risk factors and cardiovascular mortality among Australia’s immigrants concluded that the incidence of risk factors known to be associated with CVDs (systolic and diastolic blood pressure, total plasma cholesterol, high-density lipoprotein cholesterol, triglyceride, low-density lipoprotein, body mass index, smoking status, alcohol consumption, leisure-time physical activity and high-density lipoprotein cholesterol to triglyceride ratio) was not sufficiently different to explain the lower than expected standardised mortality ratios among migrants in Australia. Although various studies have provided the ‘healthy-migrant effect’2 as one of the possible explanations, what is not known is whether access to and utilisation of public health services could help explain mortality differentials between migrants and Australian-born populations. Despite the migrants’ superior health profile, various studies have reported that African and Hispanic migrants in the United States (Daumit et al. 1999; Kravitz 1999; Paterson et al. 1997), migrants of South Asian background in the United Kingdom (Feder et al. 2002; Lowry et al. 1984; Shaukat, de Bono & Cruickshank 1993) and the Australian Indigenous population (Cunningham 2002) undergo fewer invasive cardiac procedures than their white counterparts. It is established that these ethnic differences in the use of cardiac procedures are not due to physician bias in recommending patients for revascularisation (Feder et al. 2002), clinical features or severity of the disease, access to hospitals in which these procedures are performed, or the ability to pay (Ford & Cooper 1995), but rather are due to patients’ preferences for treatment (Whittle et al. 1997). Personal factors such as the patient’s unwillingness to accept referral for surgery (Ford 2
The ‘healthy migrant effect’ refers to situations where migrants are seen as inherently healthier due mainly to selection prior to migration; those who migrate have better health profiles than those who stay in their country of birth. Australian immigration policy dictates that healthier settlers are selectively prioritised (Dunt 1982), a policy which has been in place for over 50 years. Additionally, the upheaval of moving to another country, in this case Australia, implies that migrants feel (and probably are) fit enough to cope with the pressures resulting from the move (Australian Bureau of Statistics 1998).
& Cooper 1995) and lack of language skills remain unexplored as barriers of access to cardiac health services (Renzaho 2002). The effect of poor language ability as a barrier to access to health services among migrants is well documented worldwide (Ahmad, Kernohan & Baker 1989; Andrea & Renner 1995; Baker, Hayes & Fortier 1998; Baker et al. 1997). In the United States, initiatives aimed at increasing the fluency of health providers in non-official languages through provision of language training have been put in place (Binder et al. 1988; Flores et al. 2000; Koff & McGowan 1999; Prince & Nelson 1995). However, the majority of studies of ethnic differences in the receipt of invasive procedures defined ethnicity based on colour (Lee et al. 2003) or country/region of birth (Feder et al. 2002). Despite this wealth of knowledge, the effect of language ability in relation to
Table 1: Cardio-vascular disease age-standardised mortality ratios among Australians, 1987–1989 COUNTRY OF BIRTH
MEN
WOMEN
ESB countries United Kingdom and Ireland
92*
91*
South Africa
89
85
Canada
96
66
United States
96
109
New Zealand
109
105
Australia
103*
104*
Greece
62*
55*
Italy
67*
55*
NESB countries
Yugoslavia Malta
87*
79*
103
124*
Germany
95
90
Netherlands
91
84*
124*
117*
80*
118
Egypt
90
122
Vietnam
30*
Poland Lebanon
35*
Malaysia
71*
59*
Philippines
81
56*
China Other Oceania (a) Central and Southern America
62*
61*
137*
165*
54*
69*
* Ratio statistically significant from 100; p
